WAVE Program Application Form

Application for WAVE (Welcoming All, Valuing Everyone) Leadership Program

To apply for this LDA Ottawa program please fully complete form below.
Welcome to our new leadership program: WAVE (Welcoming All, Valuing Everyone) Over the course of 6 weeks students will work on discovering their own leadership styles, conflict resolution styles, the importance of listening to understand, regulating to de-escalate and bringing their own flair to the table.

Students who show a keen interest could be considered for future volunteering opportunities at Sunshine Day Camp.

PLEASE NOTE: This information will be kept strictly confidential, and will only be shared with our staff and program facilitators/volunteers.

COMING SOON!

Email jade@ldaottawa.com for more information
Please indicate your relationship to the child:*

MotherFatherGuardianOther
Your Name*

First NameLast Name
Your email address*
example@example.com
Phone Number. (Please provide the number we could reach you at in the hours before and during program times) **
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Please check*

Non-LDA MemberCurrent LDA MemberNot sure - please check for me
Child Information
Child's First and Last Name*

First NameLast Name
Child's Age*
In which school board is your child's school?*

Ottawa-Carleton District School BoardOttawa Catholic School BoardConseil des écoles publiques de l'Est de l'OntarioOther
Has your child been referred to this program by their school? **

YesNo
What is the name of your child's school?
Child's Expected School Grade for the Current School Year*
Student Profile

Please provide as much detailed information as possible to assist with screening.
If your child has a formal diagnosis of a Learning Disability, please list, including who made the diagnosis and when. **
If your child has been diagnosed with other exceptionalities (i.e. ADHD, OCD, Autism, Intellectual Disability), please list, including who made the diagnosis and when **
Specify what areas your child struggles with because of their Learning Disability/difficulty (i.e. Reading difficulties, Memory, Math, Social Skills, etc.)? (even if they don't have a specific diagnosis) **
What are your child's strengths in relation to their social skills? *
Are there any medical or behavioral issues that we need to be aware of? Please specify **
Does your child have any special interests, abilities, hobbies, sports?*
Is there any additional information you would like us to know about your child?*
Academic Level

MUST provide grade level of performance; if unsure ask child's teacher
Reading:*
Spelling:*
Writing:*
Math:*
Is your child currently on an IEP? **

YesNo
Student's Current School Placement:*

Regular ClassRegular Class with Withdrawal SupportSelf-Contained Class
Waivers and Conditions of Enrollment in Social Skills Program:
1. The parent or guardian of the above-named participant, releases LDAOttawa, its directors, staff, agents and members from any loss, personal injury, accident, misfortune or damage to the above-named or his/her property, with the understanding that reasonable precautions shall be taken to ensure the health and safety of the above-named participant.

2. For the program to be effective and out of respect for volunteers we ask families to commit to attending each session of the program they register for. If you will be unable to attend a session, you must inform program facilitator with as much notice as possible.

3. For the safety of the volunteer staff and other participants, LDAOttawa has the right and responsibility to take actions such as phone calls home and possible dismissal from program if a child exhibits continual inappropriate behaviour.
I have read and hereby accept the above waivers and conditions of enrollment and give the LDAOttawa permission to share my child’s information with the appropriate staff and program volunteers.
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Application for WAVE (Welcoming All, Valuing Everyone) Leadership Program

Child Information

Student Profile

Academic Level

Waivers and Conditions of Enrollment in Social Skills Program: